Dental Assistant Registration Application Packet

1 Dental Assistant Registration Application PacketContents: 1. 642-004 ..Contents List/SSN Information/ Mailing Information ..1 page2. 642-005 .. Application Instructions Checklist ..3 pages3. 642-006 .. Dental Assistant Registration Application ..4 pages4. 642-013 ..Out-of-state Credential Verification ..2 and Online Website Links ..1 pageImportant Social Security Number Information:You are required by state and federal law to provide a social security number with your Application . If you do not have a social security number at the time you send in this Application , please read, complete, and return this form with your Application . A Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be order to process your request:Mail your Application with initial documentation and your check Send other documents not sent or money order payable to: with initial Application to:Department of Health Dental Quality Assurance Commission Box 1099 Credentialing Olympia, WA 98507-1099 Box 47877 Olympia, WA 98504-7877 Contact us:360-236-4700To request this document in another format, call 1-800-525-0127.

2 Deaf or hard of hearing customers, please call 711 (Washington Relay) or email 642-004 June 2020 (This page intentionally left blank.)DOH 642-005 June 2020 Page 1 of 3 Important background check Information: Washington State law authorizes the Department of Health to obtain fingerprint-based background checks for licensing purposes. This check may be through the Washington State Patrol and the Federal Bureau of Investigation (FBI). This may be required if you have lived in another state or if you have a criminal record in Washington State. This would be at your own expense. All information should be printed clearly in blue or black ink. It is your responsibility to submit the required forms. FApplication Fee. This fee is non-refundable. You can check the online fee page for current fees. FCheck if either apply: Request for Military Training and Experience Evaluation Spouse or Registered Domestic Partner of Military Personnel F1.

3 Demographic Information: Social Security Number: You must list your social security number on your Application . Please call the customer Service Center at 360-236-4700 if you do not have Provider Identifier Number (NPI): The National Provider Identifier (NPI) is a standard unique identifier for health care professionals available from the Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identifier. If you have a NPI number, provide this on your Name: List your full name: first, middle, and of legal name: Legal name is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court. The court must have the legal authority to change your name. We may ask you to prove your legal name. If you use any name other than your legal name on this form, your Application may be date: Provide the month, day, and year of your birth.

4 Address: List the address we should use to send any information about your Registration . Be sure to include the city, state, zip code, county, and country. This will be your permanent address with the Department of Health until we have been notified of a change. See WAC , Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if you have them. Email: Enter your email address, if you have Name(s): Indicate whether you are known or have been known under any other names. If you have a name change, you must notify the Department of Health in writing. You must include proof of this change. See WAC Instructions Checklist F2. Personal Data Questions: All applicants must answer the same personal data questions. They are focused on your fitness to practice the essential skills of this profession. If you answer yes to any questions in this section, you must provide an appropriate explanation.

5 You must also provide the documentation listed in the note after the question. If you do not provide this, your Application is incomplete and it will not be considered. Question 5 includes misdemeanors, gross misdemeanors and felonies. You donot have to answer yes if you have been cited for traffic infractions. You can getcopies of court records through the county courthouse where the conviction,plea, deferred sentence, or suspended sentence was entered. If you have been granted certificate(s) of restoration of opportunity, pleaseprovide a certified copy of each certificate. Another jurisdiction means any other country, state, federal territory, or militaryauthority. F3. Other License, Certification, or Registration : List all states, including Washington, where credentials are or were held. Attach additional pages if you need more space. F4.

6 Applicant s Attestation: You must sign and date this for us to process the Application . Other InformationCriminal history checks are conducted for all license applicants. If you answered yes to any of the personal data questions, please submit the appropriate supporting documentation as indicated on the Application . If your Application is incomplete, you will be mailed a letter regarding the deficiencies. The Application is considered incomplete if requested information is left N/A or place a line through section instead of leaving blank. The initial Registration will expire on your birthday unless the license is issuedwithin 90 days of your next birthday. See WAC 246-12-020(3). A courtesy renewal notice will be mailed to your address on record. You mustkeep your address current with us. Any renewal postmarked or presented to thedepartment after midnight on the expiration date is late.

7 Information regarding the Dental Assistant program is available on ourWeb : You cannot practice as a Dental Assistant until your license is 642-005 June 2020 Page 2 of 3 For Spouses and Registered Domestic Partners of Military Personnel Being Transferred or Stationed in Washington:Under state law, if you are the spouse or state-registered domestic partner of a servicemember of any branch of the Military, to include Guard or Reserve, and are applying for a health care professional credential in this state, you may be eligible to have the processing of your Application expedited to receive your credential more to submit with your Application should include the following: A copy of your spouse s or registered domestic partner s military transfer ordersto Washington State. One of the following: -A copy of your marriage certificate to show proof of marriage.

8 Or -A copy of a state s declaration or Registration showing you are in a stateregistered domestic partnership with a member of the Current and Former Servicemembers Requesting Evaluation of Military Training and ExperienceUnder state law, your military education, training, and experience may count towards attaining certain civilian health care profession credentials in Washington information will be reviewed by the Department of Health to determine substantial equivalency for meeting the credentialing requirements in this to submit with your health care professional credential Application should include the following: If applicable, a copy of your DD214 Certificate of Release or Discharge fromActive Duty, Member-4 or service 2 copy, or NGB-22 for National note: -A copy of your DD214 can be downloaded from the EBenefits website. -You can request a replacement copy of your NGB-22 on theNational Archives website.

9 Official Joint Service Transcript (JST) or Community College of the AirForce(CCAF) note: -JST can be sent electronically by visiting the JST website and selectingWashington State Department of Health. -CCAF transcripts cannot be sent electronically. See the CCAF website for transcript information. Verification of Military Experience and Training (VMET) or DD Form 2586. Seethe DoDTAP website. If applicable, Application for the Evaluation of Learning Experiences DuringMilitary Service (DD Form 295). See the Military Resources 642-005 June 2020 Page 3 of 3 (This page intentionally left blank.)DOH 642-006 June 2020 Page 1 of 4 Rev 0251030000 DateStampHereNote: The mailing and email addresses you provide will be your addresses of record. It is your responsibility to maintain current contact information with the Assistant Registration Application InformationSocial Security Number (SSN) (If you do not have a SSN, see instructions)Country Will documents be received in another name?

10 F Yes F No If yes, list name(s): AddressCity State Zip Code CountyHave you ever been known under any other name(s)? F Yes F No If yes, list name(s):Country Mailing address if different from above address of recordCity State Zip Code CountyBirth date (mm/dd/yyyy) F Male F FemalePhone (enter 10 digit #)Fax (enter 10 digit #)Cell (enter 10 digit #)Email addressPlease print clearly. It is the responsibility of the applicant to submit or request all required supporting documents be submitted. Failure to do so may result in a delay in processing your Application . National Provider Identifier Number (NPI) (Enter 10 digit number)Select if either apply: F Request for Military Training and Experience Evaluation F Spouse or Registered Domestic Partner of Military PersonnelDOH 642-006 June 2020 Page 2 of you have a medical condition which in any way impairs or limits your ability to practice yourprofession with reasonable skill and safety?